DEPARTMENTAL GUIDELINES/PEARLS

COVID-19

CARDIOLOGY………………………………………………………………………………….02

GASTROENTEROLOGY……………………………………………………………………….06

ICU……………………………………………………………………………………………….10

LABOR AND DELIVERY……………………………………………………………………...11

NEPHROLOGY…………………………………………………………………………………13

NEWBORN……………………………………………………………………………………...14

ONCOLOGY/HEMATOLOGY…………………………………………………………………20

PULMONARY ………………………………………………………………………………….26

PSYCHIATRY.………………………………………………………………………………….27

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CARDIOLOGY

These proposals/guidelines serve as a response to, and preparation for, the COVID-19 pandemic

for the Ventura County Medical Center and Santa Paula Hospital system. These are based on

current available literature and recommendations from specialty societies.

Consultations:

Cardiology consult is available as per usual schedule. Recommend in-person consultation only

for those that are absolutely necessary; otherwise, telemedicine is preferable so as to limit

exposure.

ICU/DOU Beds:

VCMC/SPH guidelines for admission to be followed.

1. VT/VF

2. Severe bradycardia with hemodynamic compromise

3. Acute MI

4. Acute Decompensated Heart Failure on IV diuretics/inotropes

5. Syncope with structural heart disease

6. SVT with hemodynamic compromise

Telemetry Beds:

Any COVID-19 patient discharged from ICU to floor and as per VCMC/SPH telemetry

guidelines. Not to be used for all COVID-19 patients.

STEMI :

STEMI should be discussed with the Interventionalist on Call. The patients COVID-19 status

should be communicated to the accepting provider. Recognizing that PCI remains the standard of

care for STEMI in hospitals that have PCI capabilities, our partners at CMH have not adopted a

specific TPA protocol. TPA may be considered in some patients after weighing risks and

benefits.

STEMI ACC/SCAI guidelines for cath lab during the COVID-19 pandemic:

1. Patients with confirmed COVID infection

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a. Send STEMI patients to the cath lab for primary PCI with appropriate personal

protective equipment (PPE) for the entire cath lab team. Fibrinolysis may be

considered for stable STEMI patients after weighing the risks versus benefits.

2. Patient with suspected COVID

a. Primary PCI should be performed in patients presenting with STEMI and

suspected COVID symptoms

3. Patients with no respiratory symptoms

a. Primary PCI should be performed in patients presenting with STEMI determined

to be candidates for revascularization

NSTEMI/UA:

1. Suspected or Confirmed COVID-19 Patients

a. Medical management is recommended unless there is evidence of ongoing

ischemia, hemodynamic compromise, or electrical instability

b. Elective cath can be pursued for these patients when they are less infectious

Myocarditis:

Prevalence of myocarditis is higher in critically ill patients with COVID-19. There is overlap

with ACS in terms of symptoms and diagnosis and hence physicians should be aware of this.

Steroids have been used with success as suggested in case reports. Cardiology should be

consulted if there is suspected myocarditis.

Arrhythmias:

1. For Management of arrhythmias, follow established guidelines with some caveats

a. Hemodynamically unstable tachyarrhythmias/bradyarrhythmias: Follow ACLS

guidelines

b. Atrial Fibrillation/Flutter with RVR: anticoagulation if no contraindication, beta

blockers if not in shock, IV amiodarone, IV digoxin (check renal function).

Ensure there is no evidence of pre-excitation prior to using IV BB, amiodarone,

CCB or digoxin.

c. Supraventricular Tachycardia: vagal maneuvers, adenosine, betablockers/CCBs, if

incessant and in shock, may use IV amiodarone, catheter ablation not

recommended routinely due to need for isolation. Discuss with Cardiology.

d. Stable ventricular tachycardia: Obtain 12-lead EKG, load IV amiodarone and start

gtt; may use beta blockers if not in shock

i. Rule out ischemia, correct electrolytes, wean vasopressors

ii. Other considerations: IV Mg if TdP, transvenous pacing/isoproterenol if

bradycardia

iii. Synchronized cardioversion if symptomatic/unresponsive to meds,

becomes hemodynamically unstable

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e. VT/VF Storm: IV beta blockers, Load IV anti-arrhythmic drug followed by

maintenance drips, intubate and sedate, consider transfer to quaternary care center

for advanced heart failure therapies

2. Monitoring QT interval with Hydroxychloroquine, Azithromycin, Chloroquine, and

Lopinavir/Ritonavir

a. OK to measure interval on telemetry strip to minimize risk of COVID

transmission with 12-lead EKGs

b. Stop all non-critical QT-prolonging drugs

c. Baseline measurement for QTc , then daily measurement for patients on these

drugs with documentation of the QTc while on therapy, last measurement on day

after therapy is discontinued

d. For QRS duration <120 ms, QTc increase of >60 ms or QTc ≥500 ms would be

considered high-risk for torsades, consider discontinuation of drug depending on

individual clinical situation

e. For QRS duration ≥120 ms, QTc increase of >60 ms or QTc ≥550 ms would be

considered high-risk for torsades, consider discontinuation of drug depending on

individual clinical situation

f. Correct K and Mg levels if low

g. Caution is advised when considering these drugs in patients with chronic medical

conditions (e.g. renal failure, hepatic disease) or who are receiving medications

that may interact to cause arrythmias. Not to be used in patients with known

hereditary or acquired long QT syndrome.

Echocardiograms:

All inpatient Echocardiogram requests to be screened for medical necessity and urgency. Only

studies that change management or outcomes are to be performed. This applies to all

echocardiograms regardless of COVID status to minimize exposure of all patients to our

sonographers and machines and to minimize exposure to asymptomatic cases of COVID positive

patients.

After review of request consideration to be given by Attending Cardiologist for limited versus

standard echo protocol. Plan for contrast is to be made ahead of time, if possible, to minimize

wait time and decreased use of PPE. This is to be communicated to technician.

Common Indications for Urgent/Semi-urgent TTE:

1. Symptoms or conditions potentially related to suspected acute cardiac etiology including

but not limited to chest pain, shortness of breath, palpitations, lightheadedness/

presyncope/syncope TIA, stroke, or peripheral embolic event

2. Hypotension or hemodynamic instability of uncertain or suspected cardiac etiology

3. Acute chest pain with suspected MI and non-diagnostic ECG

4. Suspected complication of myocardial ischemia/infarction, including but not limited to

acute mitral regurgitation, ventricular septal defect, free-wall rupture/tamponade, shock,

right ventricular involvement, HF, or thrombus

5. Respiratory failure or hypoxemia of uncertain etiology

6. Known acute pulmonary embolism to guide therapy (e.g., thrombectomy and

thrombolytics)

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7. Evaluation of suspected pulmonary hypertension including evaluation of right ventricular

function and estimated pulmonary artery pressure

8. Reasonable suspicion of valvular or structural heart disease or re-evaluation of known

valvular heart disease with a change in clinical status or cardiac exam or to guide therapy

9. Evaluation of suspected infective endocarditis with positive blood cultures or a new

murmur

10. Evaluation of sustained or non-sustained atrial fibrillation, SVT, or VT

11. Evaluation of pericardial effusion/pericardial tamponade

12. Other indications may be determined as urgent on a case-by-case basis

Transesophageal echocardiography (TEE):

1. Only clinically indicated TEEs will be performed in urgent cases for cardiac disorders

that would put patients at risk for decompensation if deferred and not treated within the

expected duration of the COVID-19 pandemic

2. TEEs will not be done if an alternative imaging modality (e.g. off axis TTE views,

ultrasound enhancing agent with TTE, CT or cardiac MRI) can provide the necessary

information

3. Airborne precautions are required during a TEE for suspected and confirmed cases, due

to the increased risk for aerosolization

EKGS:

1. Daily EKGS are reasonable for ICU patients

2. EKGs are reasonable for clinical concern for ischemia, arrhythmia, or QTC monitoring

Biomarkers:

1. No recommendations for routine monitoring of troponins

2. BNP daily can be considered for ICU patients and ICU to floor discharges

RAAS Therapy:

Recommendation: Per the American College of Cardiology, American Heart Association and

Heart Failure Society of America joint statement (Bozkurt et al, HFSA/ACC/AHA Statement

Addresses Concerns Re: Using RAAS Antagonists in COVID-19, 2020)

1. For stable outpatients:

a. No evidence to support the discontinuation of outpatient ACEi/ARBs/ARNI’s

2. For inpatients

a. There is no evidence for routine discontinuation of ACEi/ARBs/ARNI, unless

otherwise indicated in situations including hypotension or acute kidney injury,

etc.

GASTROENTEROLOGY

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GASTROENTEROLOGY

The situation involving the COVID-19 pandemic continues to evolve. There is recent evidence

suggesting the potential for coronavirus transmission through droplets and perhaps fecal

shedding posing potential risks during endoscopy and colonoscopy to other patients and

endoscopy personnel.

What we know:

1. Cough, fever, fatigue, or sore throat are the most common symptoms in adults.

2. The incidence of GI symptoms including nausea and/or diarrhea are uncertain with some

reports below 5% and others at 50%. There have been some reports of isolated diarrhea

preceding cough and fever.

3. The virus may be present in GI secretions and viral RNA is detectable in stool.

Gastrointestinal infection and potential fecal-oral transmission must be considered.

4. Asymptomatic spread can occur during the prodromal phase (the mean incubation period is ~5

days, with a range of 0-14 days), with viral shedding greatest when symptoms begin.

5. Abnormal liver enzymes are observed in 20-30% of persons with COVID-19 infection.

6. Leukocyte counts drop in persons with COVID-19 infection, and elevated WBC is a poor

prognostic sign.

7. Older people and those listed by the CDC as vulnerable populations, including severe chronic

health conditions, such as heart disease, lung disease, diabetes, decompensated cirrhosis, HIV

with low CD4 counts, and immunosuppression, (including liver and other solid organ transplant

recipients) are at higher risk of developing more serious illness. Pregnancy may be a risk.

8. Best protection against virus transmission:

a. Wash hands

b. Don’t touch your face

c. Cough etiquette

d. Social distancing

e. Avoid crowds

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GASTROENTEROLOGY PROFESSIONAL SOCIETY

GUIDANCE ON ENDOSCOPIC PROCEDURES

DURING THE COVID-19 PANDEMIC

Below is guidance regarding how to manage the clinical procedural needs of patients during the

COVID-19 pandemic. Any decisions should be informed by the local situation and available

resources. There may be state, local and institutional rules in place that must be considered as

well. This guidance is offered until more definitive data-driven information becomes available.

For those patients for whom a procedure or appointment is not deemed immediately necessary,

each practice should implement mechanisms to assure appropriate follow-up once the immediate

impact of the COVID-19 pandemic has eased or passed.

All Elective Procedures Should Be Delayed

1. Screening and surveillance colonoscopy in asymptomatic patients

2. Screening and surveillance for upper GI diseases in asymptomatic patients, including

surveillance for esophageal varices in patients with cirrhosis

3. For patients needing interval endoscopy for obliteration of esophageal varices post-acute

bleeding, the individual circumstances of the patient need to be taken into account to

determine safety of delay (i.e., size of varices, red wale markings, CTP status of the

patient, acute bleed characteristics).

4. Evaluation of non-urgent symptoms or disease states where procedure results will not

imminently (within 4-6 weeks) change clinical management (e.g., EGD for non-alarm

symptoms, EUS for intermediate risk pancreatic cysts)

5. Motility procedures - esophageal manometry, ambulatory pH testing, wireless motility

capsule testing and anorectal manometry

Urgent/Emergent Procedures Should Not Be Delayed 1. Upper and lower GI bleeding or suspected bleeding leading to symptoms

2. Dysphagia significantly impacting oral intake (including EGD for intolerance of secretions

due to foreign body impaction or malignancy (stent placement))

3. Cholangitis or impeding cholangitis (perform ERCP)

4. Symptomatic pancreaticobiliary disease (perform EUS drainage procedure if necessary for

necrotizing pancreatitis and non-surgical cholecystitis, if patient fails antibiotics)

5. Palliation of GI obstruction [UGI, LGI (including stent placement for large bowel

obstruction) and pancreaticobiliary]

6. Patients with a time-sensitive diagnosis (evaluation/surveillance/treatment of premalignant

or malignant conditions, staging malignancy prior to chemotherapy or surgery)

7. Cases where endoscopic procedure will urgently change management (e.g., IBD)

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Key Clinical Frequently Asked Questions

Q. How do I treat a patient who presents with a positive FIT or Cologuard® who is

asymptomatic?

A. In most cases, a colonoscopy should be considered non-urgent and can be delayed by at

least 4-6 weeks and reassessed.

Q. If a patient had an upper GI bleed (PUD, non-variceal), has been put on a PPI and is

due for follow-up surveillance, should this patient have an EGD?

A. A follow-up EGD to assess large gastric ulcer healing, etc. should be able to be delayed 4-8

weeks absent any other alarm symptoms.

Q. Should all emergent EGD patients be intubated?

A. Absent other reasons that present a threat to the airway, intubation is not indicated for all

EGDs. Proper use of PPE, including N95 masks is paramount.

Q. Does a septic patient with an unknown and not obvious respiratory cause undergoing

EUS or ERCP require use of an N95 mask?

A. All EGDs require proper PPE, including use of N95 masks.

Q. Should procedures be performed on patients with intermediate level cases such as Iron

Deficiency Anemia (IDA) or mild dysphagia?

A. Decisions regarding cases such as these will need to be made on a case by case basis, taking

into account resource availability, level of community infectivity and risk to the patient.

Exceptional cases will require evaluation and approval by local leadership on a case by case

basis

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ICU

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ICU PREPAREDNESS SURGE PLAN

Beds:

beds 1 and 16 will be preferentially left open for aerosol generating procedures (AGPs);

after intubation and with adequate time allowed for aerosol to clear, intubated patient will

be moved to non-negative pressure room (i.e. ICU-1, bed 8, then bed 7, then bed 6, etc.)

If 3-7 COVID-19 patients, fill ICU 1, leaving 1 negative pressure room open for

intubations/procedures (prefer Bed 1). Patient remains in procedure room until sufficient

air exchanges have occurred to clear potentially aerosolized particles

Sufficient air exchanges occur after 45 minutes in negative pressure rooms, after 3.5

hours in non-negative pressure rooms at VCMC, and after 1.5 hours in non-negative

pressure rooms at SPH

If 8 or more COVID-19 patients, will overflow to ICU 2

If 16 or more COVID-19 patients, overflow to ICU 3, again filling negative pressure

rooms (17 & 18), 28 beds total

If sufficient volume, cohort COVID-19 patients starting in the ICU’s, preferably ICU 1>

ICU 2> ICU 3

further overflow into MS 1

prefer non-COVID ICU to be the PACU, then the OR (utilizing anesthesia ventilators if

needed)

proning may be necessary with severe ARDS COVID-19 patients. If Rotaprone bed

unavailable, manual proning will be initiated as staffing allows

Airway:

The initial airway will be managed by Anesthesia, in addition to any initial procedures (such as

CVC and arterial line placement), if time allows, to conserve PPE.

Staffing:

If we have a surge and there is a lack of staffing to care for ICU patients in the usual fashion, we

will initiate a team-caring algorithm.

LABOR AND DELIVERY

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LABOR AND DELIVERY

General Principles:

Wear a surgical mask at all times in L&D- patients, healthcare workers, visitors

Ask all patients whether they have any symptoms of coronavirus infection. Notify M.D if

you believe they do. Test for COVID-19 AND influenza

Test all admitted asymptomatic patient for COVID-19 with in-house test: SARS CoV-2

VCMC

Test triage patients who you expect will return within 24 hours: SARS CoV-2 VCMC

Doffing PPE in setting of COVID+/PUI is the highest risk step! Use hygienist.

Attend COVID rounds when on call.

ASYMPTOMATIC labor patients who are COVID negative:

Standard precautions

Asymptomatic labor patients COVID test result unknown:

Standard precautions with Contact/Droplet PPE* in active labor/2nd stage. N95 may be

worn at provider’s discretion

COVID+ or PUI with COVID test pending:

Encourage early epidural and consult with anesthesia to maintain good block

Patient wears mask

Airborne PPE*

Generally 1 nurse, and 1 physician

COVID+ or PUI with COVID test pending requires C-section:

All personnel in Airborne PPE.*

Nurse, anesthesiologist, scrub tech, surgeon prepare the OR to receive patient

Scrub tech moves table with surgeons’ gown and gloves outside the OR.

Labor nurse and labor physician transport patient to OR in PPE. Patient wearing a

surgical mask and covered with clean sheet or drape. Surgeon helps position patient.

Surgeon doffs gown and gloves, and leaves OR with N95 and goggles or face shield on.

Surgeon/assistant scrub and don gown and gloves outside the OR. Enter OR

C-section performed. Baby handed to personnel wearing clean PPE.

Baby becomes PUI-follow pediatric/NICU guidelines.

Patient transported directly to room where she will recover. Nurses may transport her in

PPE worn in OR.

Asymptomatic patients undergoing C-section with regional anesthesia –COVID status

unknown

Anesthesiologist, surgeon, assistant surgeon, scrub tech wear N95, goggles or face shield,

gown, and gloves in case patient must be intubated during the case

All others in standard OR PPE. If patient must be intubated, others will step outside to

don N95 and goggles or face shield.

Asymptomatic patients undergoing C-section -COVID negative

Standard precautions

LABOR AND DELIVERY

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Wait to clean time for COVID/PUI rooms

VCMC OR: 30 minutes after extubation/10 minutes if regional anesthesia

SPH OR: 45 minutes after extubation/10 minutes if regional anesthesia

*VCMC/SPH Labor rooms: 10 minutes after patient leaves the room.

*Contact/Droplet = surgical mask, face shield, gown, gloves *Airborne = N95 or PAPR, face shield, gown, gloves

NEPHROLOGY

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NEPHROLOGY

Renal involvement in COVID 19 infection

Lower incidence of AKI with COVID 19 infection than the SARS and MERS-CoV

infections

Higher frequency of renal abnormalities including albuminuria, hematuria and higher

frequency of azotemia

CT findings showing reduced density, suggestive of inflammation and edema

AKI is an independent predictor of patient’s in-hospital mortality

o Pathogenesis

▪ Sepsis leading to cytokine storm syndrome

▪ Direct cellular injury due to the virus (Viral RNA identified in urine

sample)

o Treatments

▪ General and Supportive management and Kidney replacement therapy

▪ Utilization of CRRT with high volume hemofiltration maybe beneficial as

seen in the treatment of SARS and MERS sepsis

COVID-19 in patients with CKD/ESKD

ESKD patients on dialysis may exhibit greater variation in clinical symptoms and

infectivity

Dialysis patients shown to have less lymphopenia, lower serum levels of inflammatory

cytokines, and milder clinical disease than other patients

In-Center HD increases the risk of transmission of infection, not only to patients

themselves but also to the medical staff, facility workers, and family members

COVID-19 in transplant patients

Due to immunosuppression, it is suspected that transplant recipients may have a greater

viral burden and shedding resulting in greater infectivity and potential spread to other

individuals

Transplant patient and immediate household contacts should avoid travelling unless

absolutely necessary

NEWBORN

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NEWBORN COVID-19 GENERAL GUIDELINES

There is a paucity of evidence with regard to transmission, pathophysiology, treatment and

prevention of COVID-19 in newborns. Guidance will be updated as medical knowledge grows.

Nursing and medical staff are encouraged to consult NICU and infectious disease experts.

Current knowledge regarding Coronavirus and fetuses/neonates

Risk of fetus being infected is very low

Current data suggest that approximately 2-5% of infants born to women with COVID-19

near the time of delivery have tested positive in the first 24-96 hours after birth. We do

not yet know if any of the newborns reported to the AAP Registry have become ill at

home following hospital discharge.

Greatest risk is horizontal transmission

Risk for perinatally-acquired COVID-19 is through contact with respiratory/droplet

secretions from mother or other caregivers

Theoretical risk of transmission through urine and stool during delivery process

Newborns do not readily aerosolize secretions.

Delivery room response team for COVID-19 positive mother

Uncomplicated delivery: NICU team not usually called

Standard delivery: decelerations, late preterm (>=35 weeks), cesarean section

o RT and RN in PPE

o RT may remain outside LDR/OR

Complex delivery: preterm (<35 weeks, congenital anomalies)

o NNP/Neonatologist + RT + RN in PPE

o RT inside/outside of room depending on delivery circumstance

Don a gown and gloves, and use either an N95 respirator mask and eye protection

/goggles, or a powered air-purifying respirator that provides eye protection.

Guidance for newborn care in baby born to COVID-19 positive or suspect mother

1. Rooming-in vs separation of mother and newborn at delivery

a. Data from the National Perinatal COVID-19 Registry suggests that the risk of

an infant testing positive for COVID-19 appears to be no greater if mother and

infant room-in together using infection control measures compared to

physical separation of the infant in a room separate from the mother.

Currently the following is recommended regarding the care of mothers with

confirmed or suspected COVID-19 and their well newborns:

NEWBORN

15

Mothers and newborns may room-in according to usual center practice.

During the birth hospitalization, the mother should maintain a reasonable

distance from her infant when possible. When mother provides hands-on care

to her newborn, she should wear a mask and perform hand-hygiene. Use of an

isolette may facilitate distancing and provide the infant an added measure of

protection from respiratory droplets. If using an isolette, care should be taken

to properly latch doors to prevent infant falls.

A mother who is acutely ill with COVID-19 may not be able to care for her

infant in a safe way. In this situation, it may be appropriate to temporarily

separate mother and newborn or to have the newborn cared for by non-infected

caregivers in mother’s room.

Healthcare workers should use gowns, gloves, standard procedural masks, and

eye protection (face shields or goggles) when providing care for well infants.

When this care is provided in the same room as a mother with COVID-19,

healthcare workers may opt to use N95 respirators in place of standard

procedural masks, if available.

If non-infected partners or other family members are present during the birth

hospitalization, they should use masks and hand hygiene when providing

hands-on care to the infant.

b. If separated at delivery: Infant will be placed in an incubator so mom can see infant

and then transported to the NICU or Pediatric unit for further care

• Sick full-term newborns or preterm newborns: Private room in NICU on

enhanced droplet + contact isolation (airborne isolation for aerosol-generating

procedures)

• One adult family member may visit if they are asymptomatic and are NOT PUI;

visitors should wear gown, gloves, procedural mask while visiting

• If the infant requires ongoing medical care for any reason, it is recommended that

the mother not visit her newborn until she meets CDC recommendations for

suspending transmission-based precautions

2. Bathing

Bathing of infant will be performed as soon as possible after birth per CDC

recommendations to prevent spread of disease through bodily fluids from birth.

3. Breastfeeding: The AAP strongly supports breastfeeding as the best choice for infant

feeding. Several published studies have detected SARS-CoV-2 nucleic acid in breast milk. It

is not yet known whether viable, infectious virus is secreted in breast milk, nor is it yet

NEWBORN

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established whether protective antibody is found in breast milk. Given these uncertainties,

breastfeeding is not contraindicated at this time.

a. Mothers should perform hand hygiene before breastfeeding and wear a mask during

breastfeeding.

b. If an infected mother chooses not to nurse her newborn, she may express breast milk

after appropriate hand hygiene, and this may be fed to the infant by other uninfected

caregivers.

c. Mothers of NICU infants may express breast milk for their infants during any time

that their infection status prohibits their presence in the NICU.

4. Inpatient procedures

a. The number of caregivers and hospital personnel entering the patient room will be

minimized to the greatest extent possible. Erythromycin, Hep B, and Vitamin K will

all be given according to the normal schedule. The hearing screen may be deferred to

outpatient at 14 days of life when newborn is not infectious.

b. If the infant requires CPAP, HFNC >2 liters/min as CPAP, or any form of mechanical

ventilation, airborne precautions must be used until infection status is determined

AND newborn is cleared of COVID-19 infection.

5. Infant testing for COVID-19

a. Hospitalized infants who develop symptoms should be tested at the time they develop

symptoms. Otherwise, infants who become ill after discharge should present to care –

ED or PCP as needed – and be evaluated/tested then. The incubation period is 2-14

days, so a negative test after birth does not rule out disease.

b. Testing should be done first at approximately 24 hours of age and again at

approximately 48 hours of age.

c. If it is planned that a healthy newborn will be discharged prior to 48 hours of age,

clinicians may choose to order a single test at 24-48 hours of age.

d. Obtain either a single swab of the nasopharynx; or a single swab of the throat

followed by the nasopharynx; or two separate swabs from each of these sites, and

submit for a single test. Place single swab in one viral transport media tube and send

to lab for molecular testing.

e. Test results:

i. If test is positive, consult ID and consider follow up testing of combined

OP/NP specimens at 48 – 72-hour intervals until two consecutive negative

tests >= 24 hours apart.

ii. If test is negative, but newborn is symptomatic, continue isolation

precautions x 14 days

iii. If COVID-19 negative infant is born to a COVID-19 positive mother,

consider repeat testing at 14 days of age, or sooner if infant becomes

NEWBORN

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symptomatic

Discharge Plan:

Asymptomatic COVID-19 positive newborn:

• Plan for frequent outpatient follow-up (either by phone, telemedicine, or in-office) through 14

days after birth.

• Use precautions to prevent household spread from infant to caregivers

• use this CDC guidance on use of masks, gloves and hand hygiene by caregivers in the home

environment and by healthcare staff in the outpatient office practice.

COVID-19 positive mom and asymptomatic COVID-19 negative newborn:

• Coordinate discharge and follow-up out-patient testing with PCP.

• Frequent outpatient follow-up (either by phone, telemedicine, or in-office) is recommended

through 14 days after birth.

• Use precautions to prevent household spread from caregivers to infant; see the CDC guidance

on use of standard procedural masks, gloves and hand hygiene in the home environment.

• While challenging in the home environment, mother should maintain a distance of at least 6

feet when possible, and use a mask and hand-hygiene when directly caring for the infant, until

EITHER (a) she has been afebrile for 24 hours without use of antipyretics, and (b) at least 10

days have passed since her symptoms first appeared (or, in the case of asymptomatic women

identified only by obstetric screening tests, at least 10 days have passed since the positive test).

• Other caregivers in the home who are persons under investigation (PUIs) for COVID-19

should use standard procedural masks and hand hygiene when within 6 feet of the newborn

until their status is resolved.

Newborn not tested:

• Treat the baby as if virus-positive for the 14-day period of observation.

• Mother should still maintain precautions until she meets the criteria for non-infectivity as

above.

NEWBORN

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ONCOLOGY/HEMATOLOGY

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ONCOLOGY/HEMATOLOGY

Considerations to determine if patients are high risk

Older patients

Poor performance status/nutrition status

Length of time on chemotherapy – new versus months/years

Patients under active chemotherapy

Multi-agent chemotherapy more high risk than single agent chemotherapy

Intravenous chemotherapy more high risk than oral “chemotherapy”

Hematologic malignancies such as leukemia and lymphoma requiring chemotherapy are

generally higher risk given the myeloablative nature of the regimens

Neutropenic Fever Considerations

More common in patients being treated for Hematologic malignancies

antibiotic recommendation is broad spectrum to cover for pseudomonas – cefepime and

Zosyn are common

General requirement is 48 hours of being afebrile, but if neutropenia subsides and there

are several cases of COVID-19 in the hospital we can consider treatment at home

Always call attending on call to review case

Blood Product Transfusions

This may be required for some of our patients

No change in protocol

Ideally quicker turn-around time to get them in and out of the hospital ASAP

Inpatient chemo

Small subset of patients (1-2% of all treatments are in the hospital)

Only reason is logistical challenges

Blood counts tend to be normal in house, but may be suppressed the week after

ONCOLOGY/HEMATOLOGY

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Version 7/23/2020

Anti-Coagulation Recommendations from the Department of

Hematology & Oncology for Hospitalized Patients with COVID-19

at Ventura County Medical Center Hematology guideline for COVID-19 has been prepared by VCMC hematology/oncology department. Due to the

emerging and often conflicting data regarding COVID-19, this document is meant to guide clinicians. This guideline

should be adapted to each specific patient based on the treating medical professional’s independent professional

judgment and consideration of the patient’s needs, and any other unique circumstances.

For Medical-Surgical COVID-19 Patients NOT in the ICU:

- Standard VTE prophylaxis should apply to all admitted patients.

- For example enoxaparin 40mg SQ daily if CrCl>30 and heparin 5000 units SQ TID if

CrCl<30. Consult dosing guideline for obese/renal failure patients.

For ICU patients or High-Risk non-ICU patients with COVID-19:

- High risk non-ICU patients are defined as those on non-invasive ventilation, including

high flow nasal cannula.

- Given the elevated VTE risk, VTE prophylactic doses are higher (intermediate dosing).

VTE prophylactic dosage would apply to duration of hospitalization, even when

stepped down to a lower acuity floor. See table below for VTE prophylaxis dosages. Of

note, higher dosage of VTE prophylaxis is considered off-label, but reasonable per

consensus amongst specialists and other hospital protocols.

- Due to inconclusive and controversial data, full dose therapeutic anticoagulation for the

purpose of VTE prophylaxis is NOT recommended. Per current assessment, risk of full

dose anticoagulation for VTE prophylaxis outweighs the benefit at this time.

- Always assess the patients bleeding risk upon initiation anticoagulation

- Hold prophylaxis if platelets <25k or high risk bleeding (such as active

bleeding/neurosurgical patients, etc). Replace prophylaxis with mechanical SCD’s.

- Therapeutic anticoagulation (LMWH preferred) recommended in the following patients

o with known DVT/PE,

o or patients with recurrent clotting of intravascular access devices (arterial lines,

central venous catheters,, CRRT)

o or patients already on direct oral anticoagulants for Afib/VTE

- TPA can be considered for documented for DVT/PE per the usual indications (eg, limb-

threatening DVT, massive PE)

ONCOLOGY/HEMATOLOGY

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For Admitted Patients Already on Some Form of Anticoagulation:

- Therapeutic anticoagulation is continued as inpatient.

- For patients already on therapeutic anticoagulation and admitted for COVID infection,

conversion from DOAC to LMWH/UFH is preferred due to flexibility of dosing as well as

decrease in drug-drug interactions.

- For patients on “maintenance” DOAC in the form of indefinite anticoagulation for

history of VTE (such as rivaroxaban 10mg daily), recommend conversion to

THERAPEUTIC LMWH dosing. The rationale is that even at a lower intensity DOAC dose,

the purpose of anticoagulation is still therapeutic anticoagulation. However, if a patient

is on prophylactic DOAC (such as rivaroxaban 10mg in the post-surgical patient), would

convert to PROPHYLACTIC LMWH dosing since the original intent is prophylaxis.

- If in doubt, consult hematology/cardiology/surgery for case specific discussion

Routine Testing for DIC:

- All admitted patients should have baseline coags PT/PTT/INR, fibrinogen, and D-dimer.

Repeat testing frequency as indicated clinically

- For ICU patients, PT/PTT, fibrinogen, and D-dimer should be tested daily

DIC Work-up in COVID-19 Patients:

- COVID-19 patients have increased incidence of DIC and multi-organ dysfunction

- In suspected DIC cases work-up with PT/PTT, D-dimer, fibrinogen

- Consult ISTH DIC score as an aid to diagnosis – MD Calc

(https://www.mdcalc.com/isth-criteria-disseminated-intravascular-coagulation-dic)

- DIC score <5- not suggestive of DIC, repeat within next 1-2 days and manage

clinically as appropriate

- DIC score >5- compatible with overt DIC and repeat scoring daily

ONCOLOGY/HEMATOLOGY

23

DIC Management in COVID-19 Patients:

- Management of DIC similar to usual protocol.

- Supportive care if not bleeding

o FFP or cryo if <150

- Platelet transfusion if below 30k

o Consider holding anticoagulation at this point

- Give blood products if bleeding

o FFP for bleeding with elevated PT/PTT

o Avoid tranexemic acid due to concern for thrombosis

- Systemic Anticoagulation indicated in the following:

o New VTE or organ failure due to clot

Possible continued VTE prophylaxis following hospital discharge:

- Prospective data is lacking with need for more information. Any decision to use post-

discharge thromboprophylaxis should consider the individual patient’s VTE risk factors,

including reduced mobility and bleeding risk as well as feasibility.

- Not all discharged patients need to be on VTE prophylaxis

- It is reasonable to utilize the modified IMPROVE score (MARINER trial) and offer post

discharge outpatient VTE prophylaxis when patients have a score of 4 or more, or score

of 2 to 3 with D-dimer >2x ULN.

- VTE prophylaxis would consist of Rivaroxaban 10mg daily 31 to 39 days

ONCOLOGY/HEMATOLOGY

24

- Not enough data for VTE prophylaxis recommendations for the never hospitalized

outpatient, although can consider utilizing same IMPROVE score as outlined

References:

• https://covidprotocols.org/protocols/09-hematology/

• https://www.massgeneral.org/assets/MGH/pdf/news/coronavirus/guidance-from-mass-

general-hematology.pdf

• https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-

hypercoagulability?search=anticoagulation%20coviid&source=search_result&selectedTit

le=2~150&usage_type=default&display_rank=2

• https://www.esicm.org/wp-content/uploads/2020/04/863_author_proof.pdf

• https://www.thrombosisresearch.com/article/S0049-3848(20)30120-1/pdf

• https://www.hematology.org/covid-19/covid-19-and-vte-anticoagulation

• https://www.ascopost.com/news/april-2020/hypercoagulability-in-critically-ill-patients-

with-covid-19/

ONCOLOGY/HEMATOLOGY

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• https://www.acc.org/latest-in-cardiology/articles/2020/04/17/14/42/thrombosis-and-

coronavirus-disease-2019-covid-19-faqs-for-current-practice

• https://www.fichier-pdf.fr/2020/04/03/covid-19-gihp-gfht-3-avril-final-3/

• https://doi.org/10.1111/jth.14768

• https://www.nejm.org/doi/full/10.1056/NEJMoa1601747

• https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0039-1701009

• https://www.thieme-connect.com/products/ejournals/abstract/10.1055/s-0040-1705137

(Modified IMPROVE Score)

• https://www.onlinejacc.org/content/75/23/2950

• https://link.springer.com/article/10.1007%2Fs11239-020-02138-z

• https://ccforum.biomedcentral.com/articles/10.1186/s13054-020-03052-9

PULMONARY

26

PULMONARY

Guideline for COPD, adult and pediatric asthma exacerbation during COVID-19

pandemic at VCMC

This guideline is based on discussion with pulmonary/critical care, pediatric critical care and

emergency medicine colleagues, GOLD recommendation, GINA recommendation and Cedars-

Sinai

Patients with COPD and asthma are at high risk for serious complications due to COVID-19.

Patients that develop an acute exacerbation of COPD or asthma may continue their

bronchodilator regimen including inhaled or oral corticosteroids. Goal oxygen saturation is 90%

or greater.

Oral/IV corticosteroids can be prescribed during acute exacerbation of COPD and asthma in the

COVID-19 pandemic.

Nebulizers should be avoided (if possible) for acute exacerbations due to increased risk of

COVID-19 transmission to other patients and health care workers.

NIV therapy with BPAP and CPAP to be avoided due to increased risk of COVID-19

transmission to other patients and health care workers.

For pediatric patients attempt therapy w/MDI and regular NC O2, but if persistently hypoxic,

increased work of breathing, or poor aeration proceed to HFNC and nebulizer treatments at the

attending physician’s discretion.

Use MDIs with spacer chamber device during acute exacerbation.

Continue maintenance bronchodilator regimen including inhaled corticosteroid during the acute

exacerbation.

No routine PFT/spirometry to reduce risk of COVID-19 transmission.

Maintain euvolemic fluid status. Fluid boluses allowed for septic or hypovolemic patients.

Medication Management

Adult Severe Asthma and COPD:

Albuterol MDI 4-8 puffs q 20 min x 3using chamber, then q 1 hr prn

Ipratropium MDI 4-8 puffs q 20 min x 3 using chamber, then q 1 hr prn

Magnesium sulfate 2 gm IVPV over 20 min (Only for asthma not COPD)

Prednisone 60 mg po, or Solumedrol 125mg IV for severe exacerbation

Pediatric Severe Asthma:

Albuterol MDI 4-8 puffs q 20 min x 3using chamber, then q 1 hr prn

Ipratropium MDI 4-8 puffs q 20 min x 3 using chamber, then q 1 hr prn

Magnesium sulfate 25 mg/kg IVPV over 20 min

Solumedrol 1 mg/kg IV Q6H for severe exacerbation

See VCMC COVID-19 Respiratory Care Guidelines

PSYCHIATRY

27

PSYCHIATRY

1. CSU

a. Telepsychiatry expansion

i. 3 CSU shifts successfully covered exclusively via telepsych last week

ii. SP and CSU currently have dedicated camera and Zoom

iii. VCMC telepsych currently via Zoom app/site on computer/iphone/tablet

(no dedicated camera yet)

iv. 5150 evaluation and decertification via telepsych approved by patient's

rights

2. IPU

a. In terms of a surge, our biggest worry is having a COVID + patient in the IPU

space. We are not equipped well to manage a COVID + patient in our space.

b. We are currently implementing measures to minimize risk

i. staff wearing masks

ii. increased hand hygiene (soap, limited hand sanitizer)

iii. no visitors

iv. patient education

v. restricting numbers in groups

vi. staff screening

c. Telepsychiatry

i. Could be rolled out in case of COVID + patients in IPU

ii. We have 2 cameras for IPU

iii. MD's conversations regarding rapid roll out and Zoom use have taken

place

iv. Zoom accounts available through TBH immediately